The purpose of this qualitative, ethnographic study is to examine end stage renal disease (ESRD) clients' experiences with an arterio-venous (AV) fistula for hemodialysis. Constructivism and a cultural negotiation model provide frameworks for the study. National programs, standards, goals, and previous research have focused on the physiological, anatomical, surgical, and technological aspects of vascular access with minimal focus on clients' experiences of vascular access. The client's assessment, care of, and protection of the fistula are integral to the fistula's survival, and yet these activities have not been systematically studied from the client's perspective. The research on self-care behaviors in ESRD clients focuses mostly on compliance and measuring biological outcomes determined by professionals. A pilot study was conducted that tested the proposed study's design and methods. In the proposed study, participatory interviews will be the primary source of data. A purposive sample of 20-25 informants will be selected to include variation in sociodemographics and length of time with an AV fistula. Data will be analyzed using qualitative analytic techniques to uncover vivid descriptions of the informant experience as well as categories of informant concerns, issues, and strategies used to cope with self management of living with an AV fistula for hemodialysis. The study's findings will form a foundation for the applicant to design nursing interventions for ESRD clients to facilitate coping with, caring for, and maintaining the integrity of their vascular access, and to develop appropriate educational and behavioral programs and materials that can ultimately contribute to more successful self-care of and use of a vascular access for dialysis. This study addresses the majority of the Agency for Healthcare Research and Quality's mission, strategic research goals, and priority populations. Because the ESRD population is primarily disabled, low-income, minority, elderly, has special needs, and require chronic health care, it is a priority population. This study supports the research findings that the AV fistula is safer, provides higher quality of care, and is more cost effective than other vascular accesses. Also, this study strives to understand the client's perspectives and experiences, so interventions can be designed and tested that assist clients to make informed decisions about self-care of their AV fistula. This study is the first of its type. This study addresses an important clinical issue that the Centers for Medicare & Medicaid Services has designated as a breakthrough initiative, Fistula First. The information gained from this study can improve client care by knowing what is important about an arterio-venous (AV) fistula from the client's perspective, the needs, and goals of clients with an AV fistula, the challenges faced by these clients, and more accurate assessment of AV fistulas by professional staff and clients. Further, the findings from the study will form a foundation to design interventions for end stage renal disease clients to facilitate coping with, caring for, and maintaining the integrity of their vascular access, and to develop appropriate educational and behavioral programs and materials that can ultimately contribute to more successful self-care of and use of a vascular access for dialysis. [unreadable] [unreadable] [unreadable] [unreadable]